162799556 phtls5 e4

Airway Management
and Ventilation
Prehospital Trauma Life Support
LessonLesson
4
Copyright © 2003, Elsevier Science (USA). All rights reserved.
PROVIDER COURSEPROVIDER COURSE

Objectives
• Identify patients in need of airway control
• Explain the need for increased oxygenation
and ventilation in the critical trauma patient
• Discuss methods of manual and mechanical
management of the airway
• Discuss common errors in ventilation of the
trauma patient
4-2

Airway Management
• Keys
• Tools
– Observation
– Listening
– Auscultation
Failing to appropriately assess the airway
Use of the wrong tool for the patient’s
condition
4-3

Anatomy - Upper Airway
• Tongue
• Noisy ventilations =
obstructed airway
– Gurgling and snoring
– Stridor and wheezing
4-4

Anatomy - Lower Airway
• Conduction region
– Trachea
– Bronchi
• Exchange region
– Terminal
bronchioles
– Alveoli
4-5

Capillary
endothelium
Alveolus
Alveolar
epithelium
Connective tissue
CO2
O2O2
Respiratory System
• Ventilation
– Delivers O2 to the
alveoli
– Removes CO2 from
the alveoli
• Gas exchange
– Across alveolar-
capillary membrane
4-6
Capillary

You are dispatched to a motorcycle and
vehicle collision. Bystanders report that the
motorcycle was traveling at about 40 mph (65
km/h) when a car pulled in front of the
motorcycle. You find the patient laying on the
pavement 30 ft (9 m) away from the crash.
His helmet is heavily damaged and has been
removed by a bystander.
4-7

Findings
• Gurgling ventilations
• Blood is seen in the upper airway
• Ventilations are rapid and labored
• Patient is cyanotic
Is this airway compromised?
4-8

Management Options
• Essential skills
– Manual clearing
– Manual maneuvers
– Suctioning
– Basic adjuncts
4-9

Manual Maneuvers
• Trauma jaw thrust
• Trauma chin lift
Attempting more invasive methods before
essential skills have been applied
4-10

Suctioning
• Used to remove secretions from the
airway
Failing to suction when needed may cause a
partial or complete airway obstruction
Overaggressive use of suctioning may
cause or worsen hypoxia
4-11

Basic Adjuncts
• Oropharyngeal airway (OPA)
• Nasopharyngeal airway (NPA)
• Dual lumen airways (Combitube®
, PtL®
)
4-12

Oropharyngeal Airway (OPA)
• Not indicated if gag
reflex present
• Best used
temporarily
• Does not protect
the trachea
4-13

Nasopharyngeal Airway (NPA)
When would you use this device?
What are its limitations?
4-14

Dual Lumen Airways
How do they work?
What are the indications
for use?
What are the
contraindications for
use?
4-15

Endotracheal Intubation
• Orotracheal intubation
• Nasotracheal intubation
• Digital intubation
Improper tube placement
Hypoxia from improper technique
4-16

Intubation with Inline Stabilization
What are the
indications for oral
endotracheal tube
placement?
When do we use the
inline technique?
4-17

Nasotracheal Intubation
When would you perform nasotracheal
intubation?
Bleeding
4-18

You arrive on the scene of a single vehicle MVC.
Your patient is a 25-year-old female who is trapped
upright in the driver’s seat. Her VR is 36 and she is
cyanotic. Gurgling sounds do not improve with
suctioning or manual maneuvers. The fire department
estimates that it will be 10 minutes before she is
extricated.
How would you manage her airway at this
point?
4-19

Face-to-Face Intubation
Oral endotracheal intubation
can be accomplished by using
nontraditional methods
4-20

Your patient is a 35-year-old construction
worker who fell 25 ft (7.6 m) and landed on
his head. His GCS score is 3. He is apneic
and is being ventilated with a BVM. Three
attempts at orotracheal intubation are
unsuccessful.
What are the airway management options at
this point?
4-21

Alternative Airway Procedures
• Laryngeal mask airway (LMA)
• Digital intubation
• Retrograde intubation
• Percutaneous transtracheal ventilation (PTV)
• Surgical cricothyrotomy
4-22

Laryngeal Mask Airway
• Advantages:
– Blind insertion
– Available in a range of
sizes
• Disadvantages:
– Aspiration can occur
– Limited prehospital
research
4-23

Digital Intubation
• Advantages:
– Blind insertion
– Requires no specialty equipment
• Disadvantages:
– Requires unconscious patient
– Takes significant practice
4-24

Retrograde Intubation
• Potentially useful in certain situations
• Requires tracheal puncture
• Needs specialized equipment
• Requires practice at manipulating guidewire
• Poor choice when anatomic distortion exists
4-25

Percutaneous Transtracheal
Ventilation
• Advantages:
– Ease of access
– Ease of insertion
– Minimal equipment
required
– No surgical procedures
necessary
– Minimal education
required
– Hypercarbia not a problem
for short-term use in first
45 minutes
4-26

Surgical Cricothyrotomy
• Airway of LAST RESORT
• Requires extensive training, knowledge of
neck anatomy, and ongoing QI/QA
• Complications:
– Hemorrhage
– Damage to vocal cords
4-27

At a college baseball game a 22-year-old
third baseman is struck in the head by a
line drive. Upon your arrival his GCS score
is 7 (E-1, V-1, M-5). His teeth are clenched
and he is vomiting.
How would you manage his airway?
4-28

Pharmacologically Assisted
Intubation (PAI)
• PAI includes the use of sedation, narcotics, and
paralytic agents
• RSI involves the use of a paralytic agent
• Benefits must outweigh the risk
• Back-up airway techniques must be anticipated and
available
• Current research does not conclusively demonstrate
improved outcome
4-29

PAI
• Indications:
– Patient requiring secure airway with
uncooperative behavior
• Relative contraindications:
– Alternative airway available
– Severe facial trauma
– Neck deformity or swelling
– Known allergy to indicated medications,
medical problems that preclude use of
medications
4-30

Drugs Used in PAI
• Pretreatment
– Oxygen
– Lidocaine or atropine
• Sedatives
– Midazolam, fentanyl, etomidate
• Paralytics
– Succinylcholine, vecuronium, pancuronium
4-31

Oxygen
• All trauma patients should receive
supplemental oxygen
• The goal is to maintain an SpO2 ≥ 95%
• If in doubt, use a device that will deliver a
concentration of at least 85% (FiO2 of 0.85)
Failing to recognize and treat hypoxia
4-32

Minute Volume
• Normal minute volume (MV)
500 mL(VT) x 12 bpm (VR) = 6000 mL air/min (MV)
– Normal MV 6000 -7500 mL
What happens when VT decreases to 250 mL?
4-33

Minute Volume
• First patient breathing
VT = 500 mL
VR = 12 bpm
MV = 6000 mL
• Second patient breathing
VT = 250 mL
VR = 30 bpm
MV = 7500 mL
4-34

What About Deadspace?
• Deadspace = VD
• First patient breathing
VT – VD = 500 mL – 150 mL = 350 mL
VR = 12
Air reaching alveoli = 4200 mL
• Second patient breathing
VT – VD= 250 mL – 150 mL = 100 mL
VR = 30
Air reaching alveoli = 3000 mL
DEADSPACE MATTERS!
4-35

Minute Volume
• Alveolar ventilation is usually inadequate in
patients who breathe slower than 12 bpm or
faster than 30 bpm. These trauma patients
will require assisted ventilations.
4-36

Assisted Ventilation
• Goal is to improve MV (alveolar ventilation)
and oxygenation
• Devices:
– BVM is the most commonly used device
– Oxygen-powered demand valve
– Transport ventilators
4-37

Bag-Valve-Masks (BVM)
• Minimum of 800 mL per breath
• 95% to 100% oxygen (FiO2 0.95 – 1.0)
• May require two or three providers
• Maintain stabilization of cervical spine
4-38

Summary
• Essential Skills
– Manual techniques
– Suctioning
– Basic adjuncts
• Endotracheal Intubation remains the gold
standard
• Options
– Dual Lumen Airways
– LMA
– Retrograde Intubation
• PTV and surgical cricothyrotomy
4-39

Summary
Aggressive management of the airway,
ventilations, and oxygenation improves
patient outcomes.
4-40

4-41
Prehospital Trauma Life Support
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162799556 phtls5 e4

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